Question 1 : Name?
Question 2 : E-mail?
Question 3 : Date Of Birth?
Question 4 : Street Address?
Question 5 : City ?
Question 6 : State?
Question 7 : Zip Code?
Question 8 : Landline?
Question 9 : Cell Phone?
Question 10 : Sex?
Question 11 : Height?
Question 12 : Weight?
Question 13 : Emergency Contact Name?
Question 14 : Emergency Contact Relationship?
Question 15 : Emergency Contact Phone?
Question 16 : Are you experiencing Erectile Dysfunction(ED) or Premature Ejaculation(PE)?
Question 17 : Do you have any special needs?
Question 18 : What are your health concerns?
Question 19 : Please list any allergies you might have?
Question 20 : Please list any medications you are currently taking?
Question 21 : Please list any supplements you are currently taking?
Question 22 : List hospitalizations or surgeries you have had with corresponding dates?
Question 23 : Most recent Blood Pressure Reading - If not sure enter N/A?
Question 24 : Have you been diagnosed with any diseases or disorders and if so, when?
Question 25 : Any prior or current diagnosis of cancer?
Question 26 : Any prior or current diagnosis of type 1 diabetes?
Question 27 : Any prior or current kidney disease?
Question 28 : Any prior or current liver disease?
Question 29 : Any surgery within the last four (4) weeks?
Question 30 : Any surgery scheduled in the next three (3) months?
Question 31 : Date of most recent full physical exam?
Question 32 : Any abnormalities noted?
Question 33 : Date of most recent blood work?
Question 34 : Any abnormalities noted?
Question 35 : In the past 15 years have you had any heart problems??
Question 36 : Do you drink more than 2 alcoholic beverages per day?
Question 37 : Do you use any street or Recreational Drugs Poppers/Rush (butyl nitrite or armyl nitrite ?
Question 38 : Do you use any other Recreational drugs (not including marijuana) ?
Question 39 : Do you use Nitrates For Chest Pain?
